Ketogenic diet for Epilepsy: A case report and review
Mahalakshmi. M*
Senior Dietician (Regional), Department of Clinical Nutrition and Dietetics, Kauvery Hospital, Trichy, India
*Correspondence: Email: [email protected]
Abstract
Epilepsy is a long-term neurological condition that results in recurrent seizures. The ketogenic diet (KD) is considered an effective alternative treatment for epileptic patients. This study aimed to identify the metabolic role of the KD in epilepsy. Ketone bodies induce chemical messengers and alterations in neuronal metabolic activities to regulate neuroprotective mechanisms against oxidative damage, to decrease seizure rate. Here, I discuss the role of KD on epilepsy and related metabolic disorders, focusing on its mechanism of action, favourable effects, and limitations. I describe the significant role of the KD in managing epilepsy disorders.
Keywords: Ketogenic Diet; KD; Seizure; Epilepsy
Introduction
Epilepsy is a prevalent neurological disorder with a lifetime incidence of 1-3%. Individuals with epilepsy have uncontrollable seizures due to irregularities in brain activity. Approximately 30% of people with epilepsy continue to have seizures even with multiple anti-epileptic drugs. Drug-resistant epilepsy affects patients’ quality of life. The ketogenic diet (KD) is being considered as a potential therapy for managing drug-resistant epilepsy and is effective in newborns with epilepsy. A literature review from 2009–2022 supports the anti-seizure and neuroprotective properties of KD in epilepsy patients. Epilepsy is a neurological condition causing a range of symptoms, including jerking, moving, and losing consciousness. Treatment options include anti-seizure medications, vagus nerve stimulators, a ketogenic diet, brain surgery, and deep brain stimulation. People with epilepsy have a higher risk of premature death due to irregular heart rhythm, breathing difficulties, and inhaling vomit during or after seizures. Epilepsy affects people of all ages, with around 50 million affected globally. Consult a neurologist or epileptologist if experiencing seizures.
What is the ketogenic diet?
The ketogenic diet, or keto diet, is a medical or therapeutic diet designed to help manage or treat a medical condition. The keto diet is suggested for children with epilepsy that continues despite medication. The keto diet is high in fat, adequate in protein and very low in carbohydrates (carbs). A typical keto diet comprises 70–80% fats, 20% proteins and 5–10% carbohydrates. Epilepsy is a chronic brain disorder that causes seizures, which are abnormal electrical discharges in the brain. Epilepsy is characterized by recurrent seizures that occur when there are two or more unprovoked seizures.
Benefit from a Keto diet for Epilepsy
The ketogenic diet has been used to reduce seizures since the 1920s. The mechanism by which the seizures are regulated is poorly understood. Both the low sugar and high-fat components uniquely alter the brain’s’ excitability’, thereby reducing the tendency to generate seizures.
Principles of a Keto Diet for Epilepsy
To induce ketosis, you will need to reduce your carb intake and increase your fat intake. To maintain normal body function and growth, an adequate intake of dietary protein is needed. The diet is ideally overseen and directed by a neurologist (who specializes in disorders of the brain and nervous system) or a clinical dietitian specializing in the ketogenic diet. For people with refractory epilepsy, children especially, the diet may start in the hospital with a fasting period of 18 to 24 hr. (This is not necessary but may help induce ketosis quicker). The diet is then started by slowly increasing calories and the ratio of fat to carbohydrates and protein. By the end of day three, the person should be consuming the number of calories they normally consume per day. Because the keto diet does not provide all of the vitamins and minerals needed for a balanced diet, vitamin and mineral supplements are typically prescribed, most especially calcium, vitamin D, B vitamins, and selenium.
Mechanisms of Action of the KD
Different types of ketogenic diets
- The classic ketogenic diet (CKD)
- A medium-chain triglyceride (MCT) diet
- A modified Atkins diet (MAD)
- A low glycemic index treatment (LGIT).
| Diet | Percentage of macronutrients | Advantages | Disadvantages |
|---|---|---|---|
| Classic ketogenic diet | It can be any ratio, but in general a ratio of 3–4:1, 4:1 is used (90 % fat, 4 % carbohydrate, 6 % protein). It can be any ratio. | Parents know exactly how much to give of each. It is highly consistent, so there are very few variations in ketones. The dietitian can easily adjust it because they know exactly what the child is getting. Requires less record-keeping by parents | Adjusting the amount consumed according to the child's appetite can be challenging. The child should eat everything on their plate. The recommended diet allowance is often limited in protein, which is usually less than what children are accustomed to. It involves weighing and measuring. |
| Medium Chain Fatty Acid Diet | Based on a 4:1 ratio: 10 % LCT fat, 60 % MCT fat, 20 % carbohydrate, 10 % protein. | Provides more protein, Allows for larger protein portion sizes, more volume for mixing fats, and increased food variety. | The diet plan involves weighing and measuring food portions, which can be time-consuming. Meal preparation can also take up a significant amount of time. Additionally, there may be gastrointestinal side effects. |
| Modified Atkins Diet | Approximately. 1.1:1 ratio: 65 % fat, 10 % carbohydrates, 25 % protein. | To have more flexibility in adjusting meals according to changes in appetite, Provides more protein, Allows for larger protein portion sizes, enables more volume for incorporating fats, Requires less weighing, measuring, and faster meal preparation. | There are no definitive guidelines regarding fat amounts, Experimentation is required to determine the necessary fats to achieve the desired ketosis, There is generally more variability in ketone production. It requires keeping more records to allow for adjustments in the diet. |
| Low glycemic index diet | Approximately. 0.6:1 ratio: 60 % fat, 10 % carbohydrates, 30 % protein. | To have more flexibility in adjusting meals according to changes in appetite, Provides more protein, Allows for larger protein portion sizes, enabling more volume for incorporating fats, Requires less weighing, measuring, and faster meal preparation. | Information about low glycemic index foods is required, It requires keeping more records to allow for adjustments in the diet. |
How effective is the keto diet for managing seizures?
The keto diet has proven effective over time to help epilepsy. About 40–50% of children who start the keto diet have 50% fewer seizures. In addition, roughly 10–20% of children achieve more than 90% reduction in seizures.
Case Presentation
A 7-year-aged female child with 18 kg of weight was admitted with the following medical history.
| Medical History |
|---|
| Past History: Nil significant |
| Working diagnosis: Suspected Autoimmune Encephalitis |
| Diagnosis: Acute Encephalitis Syndrome |
| Important problem with this patient: Seizure |
Course in the Hospital
7 years aged, female child permeability A well-developed normal child was referred to our hospital with an initial history of fever for 2 days, followed by afebrile for 4 days. The child developed multiple episodes of seizures and high-grade fever at home and was then referred here for further management. child was started with further treatment and was shifted to PICU. Initial investigations revealed a low normal WBC count, normal electrolytes, and an MRI brain with contrast was normal except showing cerebral edema. child recurrent episodes of left focal seizures, deviation, and twitching of the left angle of the mouth. I discussed with the neurologist and intensive care unit doctors regarding the nutrition feeding. The child was 3 days’ on NPO, and on the 4th day I suggested a ketogenic diet to the patient, and we started the commercial feed and formula feed on keto diet based for the child. On the 4th day onwards, we would have started the feed at 40 ml in each feed, and every day, we were progressively raising it to 20 ml in each feed, and on the twelfth day, we gave 120 ml to the baby. The diet was supportive of the child’s development.
The poor prognosis was explained to the attendants, and they wanted to continue further treatment in ICH, Chennai; hence, the child was referred to ICH, Chennai for further management.
Sample Nutrition Chart
| Day-4 | Day-12 | ||||
|---|---|---|---|---|---|
| Time | Menu | Quantity | Time | Menu | Quantity |
| 6:00 am | Ketokid +MCT oil 1 ml | 40 ml | 6:00 am | Ketokid +sunflower oil 1 ml | 120 ml |
| 8:00 am | Ketokid +MCT oil 1 ml | 40 ml | 8:00 am | Ketokid +sunflower oil 1 ml | 120 ml |
| 10:00 am | Avocado juice +MCT oil 1ml | 40 ml | 10:00 am | Ketokid +sunflower oil 1 ml | 120 ml |
| 12:00 pm | Ketokid +MCT oil 1 ml | 40 ml | 12:00 pm | Egg blend +MCT oil 1ml | 120 ml |
| 2:00 pm | Avocado juice +MCT oil 1ml | 40 ml | 2:00 pm | Ketokid +sunflower oil 1 ml | 120 ml |
| 4:00 pm | Ketokid +MCT oil 1 ml | 40 ml | 4:00 pm | Egg blend +MCT oil 1ml | 120 ml |
| 6:00 pm | Egg blend +MCT oil 1ml | 40 ml | 6:00 pm | Ketokid +sunflower oil 1 ml | 120 ml |
| 8:00 pm | Ketokid +MCT oil 1 ml | 40 ml | 8:00 pm | Ketokid +sunflower oil 1 ml | 120 ml |
| 10:00 pm | Egg blend + MCT oil 1ml | 40 ml | 10:00 pm | Ketokid +sunflower oil 1 ml | 120 ml |
| 12:00 pm | Ketokid + MCT oil 1 ml | 40 ml | 12:00 pm | Ketokid + sunflower oil 1 ml | 120 ml |
| Nutrition Requirements | |||||
|---|---|---|---|---|---|
| Day | Energy | Protein | Fat | Carb | T. Fluids |
| Day 4 | 340.6kcal/Day | 9.9g/Day | 33.13g/Day | 1.18g/Day | 400ml/Day |
| Day 12 | 1312kcal/Day | 40.3g/Day | 125.2g/Day | 4g/Day | 1200ml/Day |
The keto diet is suggested for children with epilepsy continues despite medication. The keto diet is high in fat, adequate in protein, and very low in carbohydrates (carbs). A typical keto diet comprises 70–80% fats, 20% proteins, and 5–10% carbohydrates. Epilepsy is a chronic brain disorder that causes seizures, which are abnormal electrical discharges in the brain. Epilepsy is characterized by recurrent seizures that occur when there are two or more unprovoked seizures.
Benefits of the Keto Diet
The Keto diet can provide many benefits to specific health conditions as well as general wellbeing. Here is a long list of reasons why people choose the Keto diet. Effective weight loss therapy, Reduction in appetite, Increases energy levels, Encourages less body fat, Regulates blood sugar levels, Improves epilepsy, Reduced sugar cravings, Lowers cholesterol, Lowers blood pressure, Improves and prevents risk from type 2 diabetes, Improves cognitive behaviour, Reduces migraines, Improves acne, on-alcoholic fatty liver disease, Could reduce risk of Cancer, Could benefit Parkinson’s Disease, Improves symptoms of polycystic ovary syndrome, Improves Alzheimer’s disease.
A Keto diet food list
Oils and Fats
Fats serve as a central energy source on a keto diet. Common keto-friendly oils and fat sources can include the following options: Coconut oil, olive oil, Walnut oil, plain almond butter, avocado, sunflower oil.
Dairy Products
Certain dairy products, like cheese, Butter. Ghee and cottage cheese can provide nutrients like calcium with minimal carbs.
Nuts and seeds
Certain nuts, like almonds, walnuts, peanuts, and Brazil nuts, are rich in healthy fats and Fiber. In small amounts, seeds can also make a nutritious, low-carb addition to one’s keto diet. For instance, chia seeds are packed with Fiber and omega-3, which can aid digestion and heart health. Other healthy seeds include the following options: Hemp, per tablespoon, pumpkin, flax, sesame, and sunflower seed.
Low-Carb Vegetables
Vegetables can be divided into two main categories: starchy and non-starchy. Non-starchy vegetables are generally more keto-friendly since they contain, on average, around three times fewer carbs per serving than starchy veggies. They also offer versatility in different meals; for example, asparagus, broccoli, cabbage, cauliflower, eggplant, cauliflower, greens, like collard or mustard green beans, kale onions, tomatoes, and turnips.
Meat and poultry
Meat and poultry are a staple of the ketogenic diet because they are high in fat and protein, and low in carbs. Here are some things to consider about meat and poultry on the keto diet: like chicken, turkey, pork, and beef, can provide a keto-friendly source of protein that promotes muscle health. Eggs are also a good source of protein and nutrients, like vitamins D and B12.
Fatty fish and shellfish
In general, 3 ounces of cooked fish or shellfish can provide one-third of one’s recommended daily protein amount. The following fish and shellfish contain no carbohydrates in a 3-ounce serving: salmon, mackerel, catfish, blue crab, shrimp, tuna, and tilapia.
Fruits and Berries
Keto-friendly fruits include avocados, watermelon, strawberries, lemons, tomatoes, raspberries, peaches, cantaloupe, star fruit, and blackberries.
Foods to Limit on a Keto Diet
Due to their high amount of carbohydrates, the following foods are usually avoided or minimized when following a keto diet: Bread, rice, starchy vegetables, like potatoes, certain fruits, like bananas, and sugary foods and beverages, like candy and soda.
Conclusion
In conclusion, the ketogenic diet presents a promising alternative for managing epilepsy, especially in patients who are resistant to conventional treatments. Through the promotion of ketone bodies and the alteration of neuronal excitability, the KD has shown potential in reducing seizure frequency and enhancing the quality of life for those affected by this neurological disorder. While the diet requires careful planning and strict medical supervision, its benefits can be profound, particularly for children and individuals with refractory epilepsy. As research continues to unfold, it is crucial for patients and caregivers to weigh the advantages against potential risks and limitations. Consulting healthcare professionals to tailor the ketogenic approach to individual needs is essential for achieving optimal results. If you’re considering the ketogenic diet as a treatment option for epilepsy, be proactive in discussing this with your healthcare provider to determine if this path is right for you. Together, we can work towards a brighter, seizure-free future.
Reference
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Ms. Mahalakshmi. M
Senior Clinical Dietitian
